By Abny Santicola

In the 1950s, C. Everett Koop, MD, then Children’s Hospital of Philadelphia’s Surgeon-in-Chief and later Surgeon General of the United States, had a very progressive idea. While most pediatric general surgeons were content operating on all areas of the body, Koop was one of the few who envisioned an exciting future where pediatric surgery would be subspecialized, the same way adult general surgery had become 80 years earlier. He believed that by subspecializing in different organ systems, pediatric surgeons would be better able to address the most complex problems that impact children and rapidly improve care and outcomes.

Nowhere has Koop’s vision been better realized than in the field of pediatric urology, which deals with problems that affect the system for making urine and removing it from the body. CHOP’s Division of Urology, one of the nation’s first pediatric urology programs, was formally established in 1970. Since then, the program has grown tremendously, from one full-time pediatric urologist — John Duckett, MD — to the current team of 12 pediatric urology subspecialists who diagnose, treat and manage babies, children and teens with conditions that can be painful, debilitating and life-threatening if they aren’t addressed properly.

The division’s highly focused expertise has allowed team members to take on the most challenging cases in the world. The team now cares for nearly 20,000 children and performs more than 3,000 surgeries each year using sophisticated technologies unimaginable a half century ago. Even in his infinite wisdom, Koop never could have foretold the innovations that would come from subspecializing and how dramatically those advances would improve the lives of children.

Continuing a storied legacy

When Douglas A. Canning, MD, came to CHOP in 1992, he was inspired by the Division of Urology’s rich legacy. As Division Chief, Duckett had established the first pediatric urology fellowship program in the country and the first basic science lab focused on pediatric urology. He also built CHOP’s pediatric urology service into one of the most respected in the world, and established a spirit of international exchange that continues to this day through initiatives in China, Trinidad and India that bring surgical advances to low-income regions.

Canning became Division Chief in 1997, and he has continued to blaze his predecessor’s pioneering path. Today, CHOP’s Division of Urology is consistently ranked among the top programs in the nation in the U.S. News & World Report Best Children’s Hospitals survey. It is home to many of the nation’s firsts in pediatric urology, including the first Pediatric Kidney Stone Center, which was created to address the dramatic rise in children developing painful kidney stones.

“From the time I arrived at CHOP, I have believed deeply that there is no problem too difficult for us to solve if we start with the child and work outward from there as a team,” says Canning, who holds the Leonard and Madlyn Abramson Chair in Pediatric Urologic Research. “It is inspiring to see what we have accomplished as an institution over the past 50 years.”

Global impact

In 2013, the division was instrumental in creating the Multi-Institutional Bladder Exstrophy Consortium, a collaboration between CHOP, Boston Children’s Hospital and Children’s Hospital of Wisconsin. The consortium brings the three hospitals together to share their expertise and experience to improve care for bladder exstrophy, a complex disorder in which a child is born with their bladder turned inside out and outside the body, and with an incompletely formed pelvis. If untreated, the disease raises the risk of serious infections and cancer, along with psychosocial complications.

CHOP pediatric urologist Aseem R. Shukla, MD, also spearheaded the creation of an international surgical consortium in India, where approximately 500 babies are born with bladder exstrophy each year and most hospitals lack the highly specialized surgical expertise required to treat it. The consortium not only delivers outcomes that would be expected in high-income countries, but also educates local clinicians on how to perform the procedure.

These cross-institutional initiatives to improve care for bladder exstrophy have garnered national attention from the Journal of the American Medical Association and earned the division recognition as a Center of Excellence by the Association for the Bladder Exstrophy Community.

Smaller incisions, huge benefits

No advance has revolutionized pediatric urology care more than minimally invasive surgery. The benefits of performing surgery through incisions no larger than a grain of rice cannot be overstated. Children have fewer complications, reduced pain, decreased need for opioids after surgery, shorter hospital stays, less scarring, and a quicker return to normal activity. Each year, the division performs one of the highest numbers of minimally invasive urologic procedures in the country for kidney stones and robotic surgeries for reconstructive procedures. CHOP recently became the first pediatric institution in the world to treat more than 1,000 patients with robot-assisted procedures, a groundbreaking landmark.

One of those patients was Bela, who underwent a robot-assisted, minimally invasive surgical procedure at CHOP when she was 4 to repair a birth defect that affected her kidneys. Bela is now 7 — the scars from her surgery are barely visible and her kidney function is completely normal. Her father, Chirag, an adult pulmonary and critical care doctor at a Philadelphia-area hospital, is still mesmerized by what CHOP’s urology team was able to do.

“It’s just phenomenal,” says Chirag. “Our experience at CHOP is something we’ll never forget. You always have to question the paradigm, and I think that’s what makes CHOP great. They never stop asking, ‘What if, why not?’ — and they truly put the family in the forefront.”

Whether life-threatening or basic, urologic problems can be upsetting for a child and their family and can affect a child socially, emotionally and psychologically. It can be disheartening to struggle with something that seems so easy for other kids. CHOP’s Urology team includes a pediatric psychologist who helps kids cope with the struggles of their condition.

“For me, as a parent, it’s very helpful to have a partner in helping my child overcome these challenges,” says Kim, mother of urology patient Adam, who had bathroom issues caused by anxiety. Adam was having about three accidents a week in school before he began meeting with the division’s psychologist. Since then, his anxiety over going to the bathroom has reduced significantly. Last year, he had only one accident — the whole year.

Collaboration around the world

Speculating on the future of the field, Canning predicts a day when complex urologic conditions will be cured and patients will live completely normal lives. He is also eager for greater international cooperation — where surgeons from institutions all over the world seamlessly share discoveries to catapult forward experience, understanding and treatment of the most complex conditions in the sickest children.

“Enormous progress has been made in the field of urology over the past five decades, and we continue to lead the way in advancing the field,” says Canning. “The opportunity to do better than we did the day before for a child and their family is what drives us. To take a young person and their family out of the uncertainty of a major disease and get them on the path to fruitful survival is extremely gratifying.” 

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